The nurse is assessing an intubated client with a deep partial-thickness burn to the right leg and a circumferential full-thickness burn to the chest.
The nurse notes the SpO2 decreasing from 96 percent to 90 percent and high ventilator alarms. Which finding is most concerning to the nurse?

High pressure ventilator alarm.

Increasing ventilator peak pressures.

Noticeable decreased chest and thoracic expansion.

SpO2 of 90 percent.

Answer and Explanation

The Correct Answer is C

Circumferential full-thickness burns to the chest create an inelastic eschar that restricts thoracic excursion. Knowledge of burn pathophysiology and respiratory mechanics is needed to identify life-threatening restrictive lung disease and the urgent need for a surgical escharotomy.

Choice A rationale

High pressure ventilator alarms occur when the ventilator meets resistance while delivering a breath. While this indicates a problem, it is a machine notification of the physiological restriction caused by the chest eschar and not the root observation.

Choice B rationale

Increasing peak pressures reflect decreased lung compliance or increased airway resistance. In this scenario, the pressures rise because the chest wall cannot expand, but the mechanical measurement is secondary to the physical assessment of chest movement.

Choice C rationale

Decreased thoracic expansion in a circumferential burn patient indicates the eschar is acting as a tourniquet. This prevents lung inflation, leading to rapid respiratory failure. This physical finding confirms the immediate need for an emergency escharotomy.

Choice D rationale

A SpO2 of 90 percent indicates hypoxemia, which is a significant clinical sign. However, it is a late manifestation of the underlying mechanical restriction. The priority is identifying the physical cause, which is the lack of expansion.

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Correct Answer is A

Explanation

Pancreatitis often leads to electrolyte imbalances, specifically hypocalcemia due to fat necrosis and soap formation. Knowledge of cardiac electrophysiology is required to recognize how low calcium levels (normal 8.5 to 10.5 mg/dL) affect the myocardial action potential.

Choice A rationale

Prolonged QT interval is a classic electrocardiogram finding in hypocalcemia. Low serum calcium slows the movement of calcium into the cardiac cells during the plateau phase, thereby lengthening the duration of ventricular depolarization and repolarization cycles.

Choice B rationale

A shortened PR interval is not associated with hypocalcemia. PR interval changes are more frequently linked to pre-excitation syndromes or inflammatory conditions of the heart, rather than the specific electrolyte shifts seen in acute pancreatic inflammation.

Choice C rationale

Peaked T waves are a hallmark sign of hyperkalemia, not hypocalcemia. In hypocalcemia, the T wave may actually appear flattened or inverted, but the most distinctive and supportive finding remains the elongation of the QT interval.

Choice D rationale

Elevated ST segments are typically indicative of myocardial infarction or pericarditis. While electrolyte imbalances can cause various cardiac changes, ST elevation is not the primary diagnostic indicator used to support a suspicion of clinical hypocalcemia.

A. Teach the client to use a chin-tuck technique when swallowing. B. Position the client upright during meals and remain with the client. C. Evaluate the client for signs of aspiration after meals. D. Assess the client's swallowing ability before meals.

Correct Answer is B

Explanation

Delegation to unlicensed assistive personnel requires understanding the scope of practice regarding stable vs unstable clients. Knowledge of the nursing process, specifically the difference between assessment or teaching and implementation of standard safety tasks, is required for this decision.

Choice A rationale

Teaching is a core nursing responsibility that requires specialized knowledge and clinical judgment. UAPs cannot perform initial or formal education on therapeutic techniques like the chin tuck, as they are not trained to evaluate the effectiveness of teaching.

Choice B rationale

Positioning a client upright and providing supervision during meals are standard safety tasks within the UAP scope of practice. This intervention supports safe swallowing while allowing the UAP to assist the client in a stable, repetitive manner.

Choice C rationale

Evaluation is the final step of the nursing process and must be performed by a registered nurse. Identifying signs of aspiration requires clinical observation and interpretation of physiological data, which exceeds the training and role of the UAP.

Choice D rationale

Assessment of swallowing ability is a complex task that requires clinical expertise and judgment. The registered nurse must perform the initial and ongoing assessments to determine the client's risk level and the safety of the current feeding plan..

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The nurse is assessing an intubated client with a deep partial-thickness burn to the right leg and a circumferential full-thickness burn to the chest. The nurse notes the SpO2 decreasing from 96 percent to 90 percent and high ventilator alarms. Which finding is most concerning to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects that a client with pancreatitis has developed hypocalcemia. Which electrocardiogram finding supports the nurse's suspicion?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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The nurse is assessing an intubated client with a deep partial-thickness burn to the right leg and a circumferential full-thickness burn to the chest.
The nurse notes the SpO2 decreasing from 96 percent to 90 percent and high ventilator alarms. Which finding is most concerning to the nurse?